It is a complete presentation on carcinoma penis, covering all aspects starting from premalignant lesions to details of squamous cell carcinoma penis including recent NCCN guidelines and steps of penectomy and lymph node dissection
It is a complete presentation on carcinoma penis, covering all aspects starting from premalignant lesions to details of squamous cell carcinoma penis including recent NCCN guidelines and steps of penectomy and lymph node dissection
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clinical presentation, diagnosis and treatment neoplasms of pancreas arising from different types of endocrine cells, both benign and malignant. exocrine tumours are not included in the presentation.
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2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
For more information, visit-www.vavaclasses.com
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We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
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Basic Civil Engineering Notes of Chapter-6, Topic- Ecosystem, Biodiversity Green house effect & Hydrological cycle
Types of Ecosystem
(1) Natural Ecosystem
(2) Artificial Ecosystem
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Biotic Components
Abiotic Components
Producers
Consumers
Decomposers
Functions of Ecosystem
Types of Biodiversity
Genetic Biodiversity
Species Biodiversity
Ecological Biodiversity
Importance of Biodiversity
Hydrological Cycle
Green House Effect
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The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
2. ANATOMY
The penis is a sexual organ and composed of three tubular
structures. The two dorsal structures, the corpora cavernosa,
provide erectile function and are anchored posteriorly onto the pubic
rami. The ventral tubular structure is the corpus spongiosum, which
surrounds the urethra. It expands distally to form the glans penis.
3. PHIMOSIS
There are physiological adhesions between the foreskin and the
glans penis at birth. They begin to disappear around the age of 2
years and may persist until 6 years of age or later, giving the false
impression that the prepuce will not retract. This condition
(sometimes known as physiological phimosis) should not be
confused with true phimosis in young boys. In true phimosis the
prepuce does not retract. This may result in ballooning of the
foreskin during micturition and may also result in infection
(balanoposthitis).
4. Phimosis in adults
Scarring in adults occurs as a result of balanitis (inflammation of
the glans penis), posthitis (inflammation of the foreskin) or LS. In LS
the normal pliant foreskin becomes thickened, typically whitish in
appearance and forms a constricting band that prevents retraction.
As a consequence, it is difficult to keep the penis clean and there
may be recurrent attacks of balanitis.
5.
6. TREATMENT
In physiological phimosis, no treatment is necessary or
appropriate. True phimosis causing symptoms.
Circumcision has been practiced since as early as
4000 b.c. Circumcision should not be performed in the
presence of hypospadias, penile curvature or buried
penis.
7. In infants and young boys, circumcision is usually performed at
the request of the parents for social or religious reasons. Medical
indications for circumcision in boys include true phimosis, LS
(rare under the age of 5 years), recurrent attacks of
balanoposthitis and recurrent UTIs.
In adults, circumcision is indicated when there is inability to
retract the foreskin for intercourse, for splitting of an abnormally
tight frenulum or for recurrent balanitis.
8. Recently, evidence has emerged that circumcision protects
against the spread of human immunodeficiency virus (HIV).
The virus dies quickly on a dry penis. A large-scale
programme of adolescent circumcision under the auspices of
the World Health Organization is ongoing in some African
countries.
9. The preputial retractability was assigned as per the classification given by
Kayaba et al.
• Type I – No retraction of prepuce at all.
• Type II – External urethral meatus exposure only.
• Type III – Glans exposure halfway to the sulcus of the
corona.
• Type IV – Glans exposure to above the corona at the
site of preputial adhesion.
• Type V – Easy exposure of whole glans
10. SHORT FRENULUM
Phimosis should not be confused with the condition where the
frenulum is short. It causes pain when the foreskin is
retracted. Another possible presentation is tearing of the
frenulum during sexual activity. Treatment is by frenuloplasty,
which utilizes the Heineke–Mikulicz principle to lengthen the
frenulum.
11. PARAPHIMOSIS
A tight foreskin once retracted may be difficult to return and a
paraphimosis results. In this condition, the venous and lymphatic return
from the glans and distal foreskin is obstructed and these structures
become edematous, causing even more pressure within the obstructing
ring of prepuce. Gentle manual compression and injection of a solution
of hyaluronidase in normal saline may help to reduce the swelling. A
dorsal slit of the prepuce under local anesthesia may be enough in an
emergency. These patients can be treated by circumcision if careful
manipulation fails.
12.
13. CARCINOMA OF THE PENIS
Circumcision soon after birth confers immunity against carcinoma
of the penis. Infection with HPV types 16 and 18 is a risk factor, as
are LS (Figure 85.23) and smoking. Phimosis and chronic
balanoposthitis are known to be contributory factors and there are
definite precancerous states including leukoplakia of the glans,
which is similar to the condition seen on the tongue, and penile
intraepithelial neoplasia (PeIN).
14. INVESTIGATIONS
A biopsy should be performed. MRI is
performed for local staging. Assessment of
locoregional lymph node status is essential.
15. PENILE INTRAEPITHELIAL NEOPLASIA
(CARCINOMA IN SITU OF THE PENIS, BOWEN’S
DISEASE, ERYTHROPLASIA OF QUEYRAT)
PeIN is typically seen as a red cutaneous patch on the penis. When it
occurs on the glans penis, it is known as erythroplasia of Queyrat;
when it occurs on the shaft of the penis, it is called Bowen’s disease.
There are several other benign causes of red patches on the penis;
when there is clinical doubt as to the underlying diagnosis a biopsy is
indicated. When the diagnosis of carcinoma in situ is confirmed,
treatment is by means of topical 5-fuorouracil cream, CO2 laser
ablation or surgical excision.
16.
17. PATHOLOGY
Carcinoma of the penis is most typically a squamous cell carcinoma
arising in the skin of the glans penis or the prepuce. It may be fat and
infiltrating or warty in appearance. The former often starts as leukoplakia
or PeIN; the latter results from an existing papilloma. Local growth
continues for months or years. T1 tumors are confined to the skin, with
T2 tumors invading the corpus spongiosum or the corpus cavernosum.
T3 tumors invade the urethra and T4 tumors invade adjacent structures.
The earliest lymphatic spread is to the inguinal nodes (N1 and N2
disease) and then to the iliac nodes (N3 disease). Distant metastatic
deposits are infrequent.
18. CLINICAL FEATURES
Many patients present late as a fungating/ulcerative growth either
because of embarrassment or because of misdiagnosis. About 10%
of patients are under 40 years of age. By the time the patient
presents, the growth is often large and secondary infection causes
a foul, bloody discharge. There is typically little or no pain.
19.
20. Around 50% have inguinal lymph node enlargement at presentation
but the nodal enlargement often reflects infection. In many, the
prepuce is non-retractile and must be split to view the lesion. A
biopsy should be performed to make the diagnosis. Untreated, the
whole glans may be replaced by a fungating offensive mass. Later, the
inguinal nodes can erode the skin of the groin and, in rare cases,
death of the patient can result from erosion of the femoral or external
iliac vessels.
21. TREATMENT
Management is divided into treatment of the primary tumor and
treatment of the inguinal nodes. Patients with small lesions of low
grade and low stage are treated with organ-preserving surgery,
such as limited excision, Mohs’ surgery or laser ablation. Mohs’
micrographic surgery is based on sequential tissue excision under
repeat microscopic control. This helps in accurately identifying the
tumor margin and maximally preserves the uninvolved tissues.
22. For most primary tumors surgical excision is the mainstay of
treatment, with the traditional view that a 2-cm margin of normal
tissue be removed being superseded by a more recent, more
conservative view, such that penis-preserving surgery with excision of
much lower margins of normal tissue is now accepted. Tumors
affecting the glans penis require lensectomy, with more advanced
tumors requiring partial penectomy. In advanced cases, total
penectomy is required with the formation of a perineal urethrostomy.
These techniques are indicated even in advanced metastatic disease for
reasons of local control.
23. Treatment of any associated enlarged inguinal lymph nodes should
be delayed until at least 3 weeks after local treatment of the primary
lesion. Enlargement caused by infection will usually show signs of
subsiding with antibiotic treatment. For palpable nodes, ultrasound-
guided fine-needle aspiration will confirm the diagnosis and a block
dissection of both groins should be undertaken. The management of
patients where the nodes are not palpable involves the use of
sentinel lymph node biopsy (SLNB) followed by inguinal node
dissection if the SLNB is positive.
24. Management of the pelvic nodes is controversial. When they are
involved on CT scanning, surgery probably has little role; however,
when the iliac nodes are not enlarged in the presence of N2 disease,
the options are observation, pelvic lymphadenectomy or
radiotherapy. Chemotherapy is relatively ineffective and currently is
reserved for palliation in those with metastatic disease. The
prognosis for tumors confined to the penis is good with 5-year
survival rates in excess of 80%. With nodal involvement the 5-year
survival rate falls to around 40%.
25. AMERICAN JOINT COMMITTEE ON CANCER STAGING FOR PENILE
CANCER PRIMARY TUMOR (T)
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ
Ta Non-invasive verrucous carcinoma
T1a Tumour invades subepithelial connective tissue without lymph
vascular invasion and is not poorly differentiated (i.e., grade 3-4)
T1b Tumour invades subepithelial connective tissue without LVI
and is poorly differentiated
T2 Tumour invades corpus spongiosum or cavernosum
T3 Tumour invades urethra
T4 Tumour invades other adjacent structures
26. LYMPH NODES (N)
NX Regional nodes cannot be assessed
N0 No palpable or visibly enlarged inguinal lymph nodes
N1 Palpable mobile unilateral inguinal lymph node
N2 Palpable mobile multiple or bilateral inguinal lymph nodes
N3 Palpable fixed inguinal nodal mass or pelvic lymphadenopathy
unilateral or bilateral
DISTANT METASTASIS (M)
M0 No distant metastasis
M1 Distant metastasis
27.
28. 1) CIRCUMCISION AND LIMITED EXCISION
STRATEGIES
2-cm surgical margin required for all patients undergoing partial
penectomy has been challenged
The maximum proximal histologic extent of 5 mm for grade 1 and
grade 2 tumors and 10 mm for grade 3 tumors is recommended.
Limitations of this approach include
Proximal and distal deeply invasive tumors,
High-grade tumors,
Skip lesions and
Patients with poor compliance who would not be candidates for
salvage procedures Recurrence rate is 4-6 %
29.
30.
31. 2) MOHS MICROGRAPHIC SURGERY
It involves layer-by-layer complete excision of the penile lesion
in multiple sessions (fixed tissue technique), with microscopic
examination of the under surface of each layer until the lesion is
completely excised.
Local recurrences rate of 8– 32% were highly associated with
tumor size (3 cm), advanced stage, and failure of previous
definitive therapy.
Mohs micrographic surgery best suited for patients with
carcinoma in situ or small superficially invasive tumors, with cure
rates comparable to partial penectomy.
32. 3) LASER ABLATION
Circumcision is generally recommended at the time of laser therapy, if
it has not already been done.
The four most widely used laser energy sources are: A) CO2 :
skin depth of 0.01 mm
CO2 laser represents optimal therapy for carcinoma in situ; however,
a local recurrence rate of up to 33%
B)Nd:YAG : most commonly used
depth of penetration of 3 to 6 mm
for treating small superficial penile lesions.
local recurrence rate has been approximately 20%
33. C) KTP lasers :
intermediate depth of penetration
better hemostasis than the CO2 laser
DISADVANTAGES OF LASER THERAPY
tissue for tumor grading and assessment of margins is not
provided difficulty in determining the exact depth of laser
coagulation;
inability to treat larger lesions; and
potentially difficult healing in patients who are obese,
immunocompromised, or receiving anticoagulation therapy
34. PARTIAL PANECTOMY
Partial penectomy remains the most common surgical procedure for
treatment of the primary tumor in patients with invasive squamous
cell carcinoma.
Successful local control is accomplished in the majority of patients by
amputation of the penis at least 2 cm proximal to the tumor.
Additional goals of the procedure are to preserve the ability to void in
a standing position and possibly to allow sexual function.
35.
36.
37. TOTAL PANECTOMY
Total penectomy is a bit of a misnomer, because the penis is
amputated at or near the level of the suspensory ligament of the
penis without removal of the corpora cavernosa more proximally.
It is indicated for penile tumors whose size or location would not
allow excision with an adequate surgical margin and preservation
of a remnant sufficient for upright voiding.